An Apple a Day

Gatekeepers and Changemakers

According to the adage, an apple a day keeps the doctor away. The idea speaks to the wisdom of prevention through healthy eating. Today it could easily be a metaphor for wider wellbeing. Through our choices, we’re able to do good not just for ourself but also for others. How often do we think about the people who contribute blood, sweat and tears to the production and distribution of the apples and all the other commodities we buy and consume?

What does all this have to do with visiting the doctor? Or not as the case may be. Well, the answer just might be, “more than we think.” The lifestyle medicine movement has been causing ripples in the clinical world. Not least in regard to when and for what reason we should be able to see the family doctor. It is also creating an increased appetite for conversations about nutrition, emotional balance, spiritual health and prevention in general. Not surprising when the pressure has been most acutely felt within the GP community who for decades have borne the brunt of social change, at some personal cost, it should be said.

Gatekeeping is a Great Gig Until the Game Changes

GP’s understand the power of conversation. When all is said and done, it’s been the de facto currency of primary care in the UK. At the risk of over-simplifying matters, patients make an appointment and come in for a chat. Fees and politics to one side, that was the practical implication of the NHS’s most exalted founding principle.

With hindsight, the unwritten rule of a 15-minute consultation window was a luxurious allocation of scarce resources. On the face of it, ample enough time to get a sense of the underlying needs of the person, yet woefully inadequate for understanding the systemic needs of the population they represent. That, of course, was someone else’s job, namely commissioners and public health professionals.

Who Feels the Pain When Systems Fail?

Years of steadily increasing demand meant fewer precious minutes for conversation; fewer appointments and as a result more system pressure. Ironically, incentive schemes like the Quality Outcome Framework (QOF) also meant more red-tape and arcane governance processes. GP stress-levels and burn-out rates are an open secret and fewer medical students are opting for general practice as a career choice. GPs have been the gatekeepers to a care system that has been struggling to keep up with unprecedented rates of socio-economic change for those who have been agitating for change.

With change comes system risk. In terms of social justice outcomes, there is a point where communities are most creative and agentic, and another, diametrically opposed, where statutory services are perfectly designed to look after citizens at greatest risk. The shortest path between those points (as illustrated by the “delineation of risk” equation) will have created concurrent demand streams (or virtual “waiting rooms”) for GP appointments.

Uncertainty Is the New Order

Some of these “waiting rooms” are populated by people looking for help with social issues such as housing, employment, isolation and general life stresses. Others, by people who may be showing early signs of serious (even life-threatening) illness. In either case, it takes space, time, effort and skill from both patient and doctor to explore the underlying needs through conversation. For a service that is primarily designed around a medical model, this is deeply problematic. So like most health and social care systems across the world, the UK’s is moving with the times.

As the tectonic plates continue to grind and slowly shift under the weight of progress there is something about the new order of uncertainty that somehow bodes well. With less time to talk and connect on a humanistic level, this particular brand of gatekeeping becomes an inscrutable choice between referring on; medicating or sending folk away to maybe come back in a couple of weeks, if they still feel unwell. After all, you can never be too sure. Unless you feel you can do a better job than the people who are making your job unnecessarily difficult. In which case, like the proverbial apple, the solution is simple.

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